Community Meeting 2
1 February 2012
Agenda
Topic
Start Time
Speaker
1. Counties to be included in project
6:30 pm
Lyman Dennis
2. HIE: What’s in it for patients? A
physician’s perspective.
6:40 pm
Peter Mathews,
MD
3.Vision statements
7:05 pm
Marty Malin &
Tim Wilson
4. What do we want to accomplish?
7:15 pm
Group
5. Organization approaches
7:30 pm
Lori Sklar &
Carl Thomas
6. What services do HIEs provide?
7:40 pm
Kathy Ficco,
Justin Graham, MD
Dave Minch
7. Models for funding HIE activities
7:55 pm
Suzanne Ness
8. Resources available
8:05 pm
Dave Minch
9. Name of Community group?
Next meeting
Group
10. Discussion
8:10-8:30 pm
Group
Service Areas for Inclusion
Lyman Dennis
Organizer & Facilitator
Approach

Looked at Dartmouth Atlas data
◦ Uses two Medicare referral types
 Major cardiovascular surgery
 Neurosurgery
to aggregate 3,436 hospital service areas into
306 hospital referral regions
◦ Counties are split
◦ Diagram: to nearest county
Conclusions





Sacramento is the center of a separate service
area
Yolo is closely related to Sacramento for
Medicare patients
Yolo is part of PHC and is involved in the MediCal systems of care with the other PHC counties
Communicare uses Redwood Community Health
Network in Sonoma for its eCW EHR
Recommendation
◦ Omit Sacramento
◦ Retain Yolo
DISCUSSION
Health Information Exchange

What’s in it for Patients?

A Physician’s Perspective
By Dr Peter Mathews
 Kaiser Permanente Napa
 02/01/12

Definition of Health Information
Exchange

Secure, Standardized Electronic Transfer
of Health Information

Among Health Care Organizations
(hospitals, office, labs, pharmacies, the
patient, SNF,etc)

For improving Health (Quality), improving
Experience of Care, and reducing Cost
Key Attributes of High Performing
Health Care Organizations
Organization wide focus on the needs of
the patient
 Strong organizational and clinical
leadership
 Access to info to support EFFICIENT,
COORDINATED CARE
 Timely access to care
 Emphasis on Prevention, Wellness and
Healthy behaviors

Enabling New Patient Centric
Models of Care
Better telephone and e-visits enabled
because of presence of clinical information
 Teledermatology
 Telemedicine
 Population management

◦ Better preventive care (paps, Mammos, etc)
◦ Better chronic disease management (Diabetes)

Reduced rate of hospital readmission
Who Needs the Info
The Patient
 Primary Care Physician Offices
 Specialist Physician Offices
 Lab, Pharmacies and Radiology
 Health Plans
 Long Term Care Facilities
 Hospitals/Emergency Departments

What Information is the most
Clinically Important to Exchange?
•
•
•
•
•
•
•
•
Problems
Meds
Allergies
Immunizations
Problem List
Screening
Advance Directive
Recent Discharge Summaries/H&P/Op
Note
Scenario 1 – ED to Physician office

60 yo man is seen at Local Emergency
department with Chest Pain. Is evaluated
there and discharged home. Comes to
his doctors office 2 days later. Need for
ED Visit record and EKG from the ED
Scenario 2 Doctors Office to
Hospital

88 yo lives at home with is wife. He has
previous filled out an Advanced Directive
stating he wishes no heroic measures.
This is at his doctor’s office. He collapses
at home, is found by a neighbor, and he is
intubated and has a prolonged
hospitalization
Scenario 3 Hand off Between
primary care and specialty care

45 yo female develops arthritic symptoms.
Xray and blood tests for arthritis are
done – patient is referred to Specialist Results are not available. Studies are
repeated. Patient was allergic to one of
the drugs prescribed. Was in family
doctors records but patinet forgot to tell
this to the specialist.
Scenario 4

45 year old woman previous had care at
the local community clinic and states she
had a mammogram in the last year. It
turns out it’s been 3 years. Mammogram
not ordered. Patient presents with
advanced breast cancer.
Exchanging Clinical Information
Where do we start?
 What has been our experience in Kaiser
Permanente?

What we did First
Lab
 Medications
 Radiology online


Soon thereafter
◦ Allergies
◦ Problem List
Next

Discharge Summaries (transcriptions)

Next we implemented an Ambulatory
Electronic Health Record (Epic)

Next we implemented an Inpatient
Electronic Health Record (EpicCare
Inpatient)
And the last lap

We implemented Secure Messaging to
our Members

In the last 6 months we turned on
◦ Care Epic
◦ The ability to View Records on Kaiser Patients
from other Kaiser regions (e.g. Southern
California)

We scan in Advanced Directives
SNAPSHOT (SUMMARY CLINICAL
RECORD)
Allergies
Medications
Status on Preventive Tests
(pap smear, mammo, colon ca
screening, etc)
Immunizations
Lab results (and or trend) note
prior Vital Signs (weight, bp)
Last Cardiac Studies (EKG as an
example)
Advance Directive
Scan of Advance Directive
Kaiser Example of Health
Information Exchange (WITHIN
Kaiser regions)

CARE EPIC
◦ Almost the entire record - but VIEW only
◦ Following slides
 How the care team pulls up the record
 What the record looks like once pulled up
CARE EPIC (requesting a view only
record from another Kaiser region)
Requesting Record (slide 2)
Viewing Record
Viewing Record (part 2)
Viewing record (part 3)
Exchange of Clinical Information is
Important

It promotes Quality Health Care
◦ Preventing harm to patient from adverse
reactions
◦ Preventing over utilization of narcotics
◦ Insuring patients are up to date on preventive
care and chronic disease lab monitoring
Reducing Cost
It prevents duplication of tests
 It ensures good communication and
coordination of care among different
members of the health care team
 It enables new models of care

◦ Teledmedicine, population management,
Begin at the Beginning
Meds
 Labs
 Pharmacy
 Problem List
 Allergies


Then Transcriptions/ ED visits/Discharge
summaries - the journey begins!
DISCUSSION
Vision Statements
H. Martin Malin, PhD, MA, MFT
Interim Mental Health Services Act Coordinator
Solano County Health and Social Services
Tim Wilson, PhD
Epidemiologist
Yolo County Health Department
To Improve Individual Health
Outcomes in the NE Bay Area






Support continuity of care
Promote appropriate clinical decision making at
the point of service
Make information available and useful
Improve patient safety
Improve and enhance the patient/clinician
experience
Support achievement of systematic goals such as
◦ Clinical analytics,
◦ Population health management &
◦ Implementation of best practices
Reduce adverse outcomes and costs
associated with
Treatment decisions made based on
incomplete or patient-recall data when
better data is available
 Lack of patient engagement in their own
healthcare due to lack of understanding of
key health drivers and test trends

Provide connector technology that

Reliably exchanges
◦ Physical health
◦ Mental health and
◦ Alcohol and substance use
information among providers
 Rapidly provides requested data
 Anticipates connection with other HIEs
regionally and nationally
DISCUSSION
What do we want
the group to accomplish?
Lyman Dennis
Organizer & Facilitator
Why HIE?
Rationalize medical care
Allow continuity of care across providers
 Provide more (all) clinical data at point of
care
 Support evidence-based medicine by
allowing review of more (all) information
about each case
 Reduce duplicate analytical studies
 Support ACO reimbursement incentives

Options for the Community Group
1.
2.
3.
4.
Do nothing. Disband.
Set up a full HIE organization and
business.
Set up an organization to contract for
HIE services.
Set up a collaborative to coordinate the
contracting for services.
1. Do nothing.
HIE will develop chaotically and without
plan for integration.
 Analogous to unplanned ER services.
Competition for victims or no ambulance
when needed.
 Likely to be

◦ More expensive
◦ Contain gaps
◦ Have unlinked HIE service silos
2. Build a full HIE organization
& business
Time is past when a full-service HIE (like
Santa Cruz HIE) can gain all the exchange
services for a county or group of counties.
Already have distinct functions and HIEs
operating.
 Cost of a full HIE organization is relatively
high – staff, policies & procedures, hardware,
software, infrastructure, etc.
 Not necessary as less-expensive alternatives
available.

3. Set up an organization
to contract for HIE services

A number of organizations provide HIE
services
◦ Existing HIEs
◦ Vendors

Having a Community organization do this
allows
◦
◦
◦
◦
Negotiation leverage
Economies of scale
A forum to agree on a common approach
A way to coordinate community resources
related to HIE
4. Set up collaborative to coordinate
contracting for services
Bring community together
 Develop a coordinated plan
 Provide some negotiation leverage but
not as much as a single entity
 May have a long-term role or may fade
 A community voice

DISCUSSION
Organization Approaches
Carl Thomas, Interim Executive Director, Solano
Coalition for Better Health
Lori Sklar, Executive Director, Redwood Community
Health Network
Nonprofit Structure
Looked at organizational models for
other HIEs
 Nonprofit appears most appropriate for
community effort
 Relatively easy to incorporate
 Application for not-for-profit status timeconsuming but not difficult

Participation
Stakeholders influential in developing
community solutions
 Interest in making data sharing work

◦ Allow physicians and other caregivers to see
recent care
◦ Improve outcomes
◦ Enhance patient experience
◦ Decrease duplication
Avoid Pioneering
Build on experience of other groups
 Begin with available documents
 Don’t redevelop successful work of
others
 Utilize best practices
 Do what is needed to assure success

DISCUSSION
HIE Service Offerings By
Category
Paul Alcala, VP CIO NorthBay Healthcare
David Minch, HIPAA/HIE Project Manager John Muir Health
Kathy Ficco, Executive Director, St. Joseph Health System
Justin Graham, CMIO NorthBay Healthcare
Lyman Dennis, Organizer/Facilitator (matrix)
Basic “Core” Services:

Foundational Services:
◦
◦
◦
◦
◦
◦
Master Patient Index
Record Locator
Provider Directory
Entity Directory (Hospitals, Med Groups, etc.)
User Directory
Other Directories (Clinics, Public Services, Registries, non-participant message
destinations, etc.)
◦ Authentication / Authorization Methods
◦ ATNA Standard Transaction and Use Logs

Transaction Services (Hospital & Ambulatory):
◦ Inbound Interfaces EHRHIE
◦ Outbound Interfaces HIEEHR

Application Services:
◦ Consent Management (Opt-In, Opt-Out)
◦ Secure Clinician-Clinician Messaging / Referrals
◦ Gateways (NwHIN, other local HIEs, State HIEs, Direct HISP, Immunization
Registry, Public Health)
◦ Portal to view the “Community Record”
◦ Results Distribution
Specialty “Premium” Services:
◦ Physician EMR-Lite
◦ Full EMR with HIE or contracted Installation /
Support
◦ Other Physician Products (eRx, practice
management, home device monitoring)
◦ Personal Health Record (PHR)
◦ Dictation Services
◦ Disease Registries
◦ Public Health and Immunization Reporting and
Inquiry
◦ Advance Directives
◦ Group Purchasing
Clinical Data & Workflow:
Clinical Information
◦
◦
◦
◦
◦
◦
◦
◦
Diagnosis / Problem List
Allergies
Laboratory Values
Radiology Transcription
Discharge Summary
Visit Summary
Immunization
Medication Summary
Workflow
◦
◦
◦
◦
◦
◦
Referrals
Authorizations
Encounters (ED, Ambulatory, Inpatient)
Transition of Care support
Home Health Reporting
Image & other Dx Reporting
Data Warehouse & Analytics:
Clinical Management
◦
◦
◦
◦
◦
◦
Clinical Quality Reporting
Clinical Disease Registries
Chronic Disease Management and Reporting
Immunization Registries
Syndromic Surveillance Reporting and Monitoring
Clinical Decision Support
Management Analytics
◦
◦
◦
◦
◦
Insurance Claims Analytics
Regional Population Analytics
Clinical Trials Data Base
Public Health Case Mgmt
ACO Metrics
Data Accessibility:
Patient Community Record
◦
◦
◦
◦
◦
Hospitals / Acute Care
Ambulatory / Outpatient Clinics
Home Health / Rehab
SNF / Long Term Care
Care Continuum – Merged Encounter Data
Financial and Administrative Services:
◦
◦
◦
◦
◦
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Claims Processing to Payers
Eligibility Verifications
Remittance Advice Processing
Physician Credentialing Services
Billing Services
Attachments
HIE Services Defined by Participants
DISCUSSION
Models for Funding HIE
Activities
Suzanne Ness
Regional Vice President
Hospital Council of Northern & Central California
Funding of Interest?
Beginning as a collaborative, not a formal
startup HIE
 Long organizational road to be a full HIE
& not necessary
 Better to

◦ Contract for services or
◦ Coordinate provider services so community
exchange makes sense
Funding Models (for Full HIEs)

HealthBridge, Cincinnati
◦ Founded in 1997 with $1.75M in unsecured
loans
◦ Two health plans/five hospitals -- $250k each
◦ All loans repaid, continuous operation14 years
◦ Sustainable w/o grants (5-8% annual return;
only 3% from grants)
Funding Models (full HIEs) - 2

Santa Cruz HIE
◦ Founded in 1995 by Physicians Medical Group of Santa
Cruz, Dominican Hospital and Unilab (now Quest) as a
for-profit.
◦ $300k to $500k from each partner, given to Axolotl to
develop software
◦ Founder users paid subscription from day one
◦ Driven by physicians

Redwood MedNet, Western Health
Information Network (nee Long Beach
Network for Health)
◦ Grant funded startup and early operation
◦ Cal eConnect providing matching expansion funds
◦ Still grant dependent but moving to user funding
Funding Options
Grants – not sustainable permanently
(CareSpark in Tenn expired when grants
ran out.)
 Transaction-based fees – discourage use
of services
 Subscriptions – HealthBridge, Santa Cruz
HIE, Utah Health Information Network

Examples of Subscription Charges
◦ Per MD per month: core services, with additional
cost for EHR ‘lite.’
◦ Hospitals: by bed or occupancy, per month charge
◦ Community clinics: a single MD rate, per location
◦ Free clinics: free
◦ Home health: annual cost based on revenue
◦ Ambulatory surgery: based on number of MDs
◦ Long-term care/post acute: annual based on number
of beds
◦ Independent labs: per ordering provider per month,
per lab (Quest, LabCorp, others)
◦ Pharmacy: per year, per location
Specialty “Premium” Services:
◦ Physician EMR-Lite
◦ Full EMR with HIE or contracted Installation /
Support
◦ Other Physician Products (eRx, practice
management, home device monitoring)
◦ Personal Health Record (PHR)
◦ Dictation Services
◦ Disease Registries
◦ Public Health and Immunization Reporting and
Inquiry
◦ Advance Directives
◦ Group Purchasing
DISCUSSION
Resources
David Minch
HIPAA/HIE Project Manager
John Muir Health
Resources

Sources
◦ From other HIEs (on HIE web sites and in
contributed documents)
◦ HIMSS HIE Guides & Toolkit
◦ eHI (eHealth Initiative)
◦ Markle – Connecting for Health
◦ NeHC University
◦ Vendors – webinars and supplied docs
◦ NwHIN DURSA
DISCUSSION
Name of Community Group
Next Meeting
Suggested Homework for
Coordinating Committee
Group
Homework

Mission, organization and budget for -◦ Contracting organization
◦ Collaborative organization

Next meeting: discussion of alternatives
and implications